1. with Stroke-Induced Aphasia: A Systematic Review
Examining the Effects of Treatment Intensity and Constraint-Induced Language Therapy for Individuals
with Stroke-Induced Aphasia: A Systematic Review
Anastasia Raymer Janet Patterson Leora Cherney Rob Mullen Tracy Schooling Tobi Frymark
Old Dominion University California State Univ. East Bay Rehabilitation Institute of ASHA ASHA ASHA
Norfolk, VA Hayward, CA Chicago, IL Rockville, MD Rockville, MD Rockville, MD
OVERALL FINDINGS
Treatment Intensity – 6 studies with 68 participants
Language impairment measures: Increased treatment intensity was associated with positive changes in both chronic and acute aphasia.
Activity/Participation measures: Equivocal results, favoring neither more intensive nor less intensive treatment for persons with chronic aphasia.
Observations suggest that there can be complex interactions among intensity of treatment schedule, type of treatment, and type of outcome measure.
Maintenance of treatment: little data; also equivocal, favoring more intense treatment for one outcome measure and less intense for the other.
CILT - 5 studies with 90 participants
Language impairment measures: CILT resulted in positive changes
Communication activity/participation measures: CILT reported to lead to positive changes, though no effect sizes calculable
Data available only for chronic aphasia. No data speak to the effects of CILT in acute aphasia.
Maintenance of CILT effects: reported to lead to positive changes; again no effect sizes calculable.
Discussion
Across studies, majority of participants were nonfluent and moderately impaired; therefore generalizability of results is limited for individuals with fluent aphasia and individuals with mild and severe aphasia.
Future studies need to tease out more carefully the impact of constraint and intensity on outcome.
Future research must be designed according to the criteria included in the ASHA levels of evidence scheme to ensure that they are of highest quality.
Future studies should address issues of effectiveness and cost effectiveness
METHODS
RESULTS
BACKGROUND AND PURPOSE
American Speech-Language-Hearing Association (ASHA) has targeted evidence-based practice (EBP) as a Focused Initiative, and has established mechanisms to support EBP:
Developed Levels of Evidence (LOE) System
Overseeing series of Evidence Based Systematic Reviews (EBSRs) of topics relevant to Speech-Language Pathology and Audiology
Constraint Induced Language Therapy (CILT) for Aphasia
(Pulvermuller et al., 2001)
Forced verbal language use – no compensatory strategies
Intensive treatment schedule – 3 hrs/day, 5 days/week for 2 weeks
Shaping verbal responses – move to longer utterances
Question: Unclear whether positive CILT outcomes pertain to forced language use or intensive treatment schedule?
Pilot EBSR: To review evidence for effects of CILT and intensity of aphasia treatment
Framing the Clinical Questions
Population – Intervention – Comparison - Outcome
P - stroke-induced chronic aphasia,
stroke-induced acute aphasia
I - CILT and intensive aphasia treatment
C – contrasting treatment or no treatment
O - measures of language impairment,
communication activity/participation, maintenance
5 Questions Pertaining to CILT
For stroke-induced chronic aphasia, what is the influence of treatment intensity on measures of language impairment?
For stroke-induced chronic aphasia, what is the influence of treatment intensity on measures of communication activity/participation?
For stroke-induced acute aphasia, what is the influence of treatment intensity on measures of language impairment?
For stroke-induced acute aphasia, what is the influence of treatment intensity on measures of communication activity/participation?
For stroke-induced chronic aphasia, what treatment outcomes are maintained following intensive language treatment?
5 Questions Pertaining to Treatment Intensity
For stroke-induced chronic aphasia, what is the influence of constraint-induced language therapy on measures of language impairment?
For stroke-induced chronic aphasia, what is the influence of constraint-induced language therapy on measures of communication activity/participation?
For stroke-induced acute aphasia, what is the influence of constraint-induced language therapy on measures of language impairment?
For stroke-induced acute aphasia, what is the influence of constraint-induced language therapy on measures of communication activity/participation?
For stroke-induced chronic aphasia, what treatment outcomes are maintained following constraint-induced language therapy?
Included Studies
CILT Intensity
Maher et al., Basso & Caporali, 2001
Meinzer et al., Denes et al., 1996
Meinzer et al., Hinckley & Craig, 1998
Pulvermuller et al., Hinckley & Carr, 2005
Pulvermuller et al., Pulvermuller et al., 2001
Raymer et al., 2006
Rating the Evidence
ASHA Levels of Evidence System (Mullen, 2007)
Dimensions Highest Quality
Study Design Controlled trial
Blinding Assessors blinded
Sampling Random sample adequately described
Group Comparability/ Groups comparable at baseline
Participants described Participants well described
Treatment Fidelity Evidence provided
Outcomes Valid & reliable outcome measure
Significance p value reported/calculable
Precision Effect size & confidence interval reported/calculable
Intention to Treat Analyzed by intention to treat
(controlled trials only)
Ratings
2 reviewers rated each article for quality & stage of research
National office staff tracked agreement in reviewers
One article authored by committee member (AMR) was reviewed by two other reviewers
References
1) Basso, A. A. & Caporali, A. (2001). Aphasia therapy or the importance of being earnest. Aphasiology, 15,
2) Denes, G., Perazzolo, C., Piani, A. & Piccione, F. (1996). Intensive versus regular speech therapy in global aphasia: a controlled study. Aphasiology, 10,
3) Hinckley, J. J. & Craig, H. K. (1998). Influence of rate of treatment on the naming abilities of adults with chronic aphasia. Aphasiology, 12,
4) Hinckley, J. J. & Carr, T. (2005). Comparing the outcomes of intensive and non-intensive context-based aphasia treatment. Aphasiology, 19,
5) Maher, L., Kendall, D., Swearengin, J., Rodriguez, A. Leon, S., Pingel, K., Holland, A. & Rothi, L. (2006). A pilot study of use-dependent learning in the context of constraint induced language therapy. Journal of the International Neuropsychological Society, 12,
6) Meinzer, M., Djundja, D., Barthel, G., Elbert, T. & Rockstroth, B. (2005). Long-term stability of improved language functions in chronic aphasia after constraint-induced aphasia therapy. Stroke, 36,
7) Meinzer, M., Elbert, C., Wienbruch, C., Djundja, D, Barthel, G. & Rockstroh, B. (2004). Intensive language training enhances brain plasticity in chronic aphasia. BMC Biology, 2, 1-9.
8) Pulvermuller, F. B. Neininger, B., Elbert, T., Mohr, B., Rockstroh, B., Koebbel, P. & Taub, E. (2001). Constraint-induced therapy of chronic aphasia after stroke. Stroke, 32,
9) Pulvermuller, F., Hauk, O., Zohsel, K, Neininger, B. & Mohr, B. (2005). Therapy-related reorganization of language in both hemispheres of patients with chronic aphasia. Neuroimage, 28,
10) Raymer, A., Kohen, F. & Saffell, D. (2006). Computerised training for impairments for word comprehension and retrieval in aphasia. Aphasiology, 20,
Number of studies (max = 10) with Highest Quality Score:
Design: Controlled trial 5
Assessor blinded 2
Random sample well-described 1
Comparable groups/ Stage of Research:
Participants well-described 10
Treatment fidelity Discovery studies
Valid/reliable outcome measures 9 5 Efficacy studies
Significance calculable Effectiveness study
Precision calculable Cost/Benefit
Intention to treat 3/5